Analysis The trawlerman had approximately seven years' fishing experience and was wearing safety gear at the time of the occurrence. Although the metal in way of the upper lug was more severely corroded than that in way of the lower pad-eye, the crew deviated from the established practice and secured both the block and the safety chain to the upper lug. The section of the bulwark stay and the upper lug ripped away from the after ship's structure and struck the trawlerman, killing him. The upper section of the bulwark stay in way of the lug was severely corroded and the face flange, which was bent beyond the original 90 degrees, was readily visible. Substantial corrosion and distortion of the bulwark stay was evident for some time prior to the occurrence; however, remedial action had not been initiated. Although the pad-eye and the lug were welded on the face flange and not the standing flange, the bulwark stay in way of the pad-eye and the lug was not stiffened to provide additional strength. There was lack of coordination between the shore maintenance staff and the ship's crew, in that the deficiencies identified by the former were not brought to the attention of the latter, who would be exposed to the hazards at sea. Rigged gear used in fishing operations is not examined by the ship's crew prior to its use on a routine basis. The current follow-up procedures for deficiencies identified by the shore maintenance staff did not reflect the urgency essential for remedial measures. Effective action was not taken to correct the deficiencies identified some seven months prior to the occurrence. Safety meetings on board the vessel were not conducted on a regular basis, and those that were conducted did not meet the stated objective, in that the readily visible deficiencies were not reported by the crew and the deficiency or hazard was not discussed. The current approach lacks coordination and harmonization between the federal and provincial authorities and results in reduced workplace safety and reduced overall safety of fishing vessel. The last steamship inspection was carried out some two weeks prior to the occurrence and was less than thorough, in that it did not detect the level of corrosion of the bulwark stays. The open link safety chain had one partially wasted link, which could have rendered the chain ineffective for its intended purpose. The practice of securing the block and the safety chain to a single anchor point effectively negates the back-up prevention function of the safety chain. The method of communication on the deck , where there are varying degrees of noise is such that the transfer of information, which is critical for safe operation, is not always ensured. Immediately prior to the accident, there was no communication between the operator of the capstan winch and the trawlerman.Findings The trawlerman had approximately seven years' fishing experience and was wearing safety gear at the time of the occurrence. Although the metal in way of the upper lug was more severely corroded than that in way of the lower pad-eye, the crew deviated from the established practice and secured both the block and the safety chain to the upper lug. The section of the bulwark stay and the upper lug ripped away from the after ship's structure and struck the trawlerman, killing him. The upper section of the bulwark stay in way of the lug was severely corroded and the face flange, which was bent beyond the original 90 degrees, was readily visible. Substantial corrosion and distortion of the bulwark stay was evident for some time prior to the occurrence; however, remedial action had not been initiated. Although the pad-eye and the lug were welded on the face flange and not the standing flange, the bulwark stay in way of the pad-eye and the lug was not stiffened to provide additional strength. There was lack of coordination between the shore maintenance staff and the ship's crew, in that the deficiencies identified by the former were not brought to the attention of the latter, who would be exposed to the hazards at sea. Rigged gear used in fishing operations is not examined by the ship's crew prior to its use on a routine basis. The current follow-up procedures for deficiencies identified by the shore maintenance staff did not reflect the urgency essential for remedial measures. Effective action was not taken to correct the deficiencies identified some seven months prior to the occurrence. Safety meetings on board the vessel were not conducted on a regular basis, and those that were conducted did not meet the stated objective, in that the readily visible deficiencies were not reported by the crew and the deficiency or hazard was not discussed. The current approach lacks coordination and harmonization between the federal and provincial authorities and results in reduced workplace safety and reduced overall safety of fishing vessel. The last steamship inspection was carried out some two weeks prior to the occurrence and was less than thorough, in that it did not detect the level of corrosion of the bulwark stays. The open link safety chain had one partially wasted link, which could have rendered the chain ineffective for its intended purpose. The practice of securing the block and the safety chain to a single anchor point effectively negates the back-up prevention function of the safety chain. The method of communication on the deck , where there are varying degrees of noise is such that the transfer of information, which is critical for safe operation, is not always ensured. Immediately prior to the accident, there was no communication between the operator of the capstan winch and the trawlerman. The lug which formed part of the rigging was attached to a severely corroded face flange of the bulwark stay. While engaged in fishing operations, a section of the bulwark stay in way of the lug tore away from the structure and struck the trawlerman, killing him. The corrosion reduced the factor of safety to a point where the pull of the capstan winch together with the dynamic loading effects was able to tear the lug away from the weakened face flange of the bulwark stay. Contributing to the occurrence were the fact that the bulwark stay in way of the lug was not strengthened, the crew deviated from the normal rigging practices, the rigging was not examined by the crew prior to its use, and there was poor communication on the deckCauses and Contributing Factors The lug which formed part of the rigging was attached to a severely corroded face flange of the bulwark stay. While engaged in fishing operations, a section of the bulwark stay in way of the lug tore away from the structure and struck the trawlerman, killing him. The corrosion reduced the factor of safety to a point where the pull of the capstan winch together with the dynamic loading effects was able to tear the lug away from the weakened face flange of the bulwark stay. Contributing to the occurrence were the fact that the bulwark stay in way of the lug was not strengthened, the crew deviated from the normal rigging practices, the rigging was not examined by the crew prior to its use, and there was poor communication on the deck Following the occurrence, Nova Scotia's Department of Environment and Labour carried out an investigation into the occurrence. Under an order issued by the department, a comprehensive examination of all standing and running rigging for fishing operations including safety chains, anchor points for rigging and wire sizes of lifting purchases and rigging gear onboard was carried out for all vessels of the fleet, including the Cape Chidley. Changes, repairs and/or replacements effected to Cape Chidley included, among others, the fitting of a new header to the bulwark stay and returning the bulwark stay to its original scantlings. Following this occurrence, National Sea Products reported that the company has extensively reviewed its internal procedures with respect to the repair and maintenance of its vessels and safety training for its crews. The importance of regular safety meetings has been reinforced. Crew have continued to participate in training. In particular, the crew of the Cape Chidley have taken further training in occupational health and safety, incident investigation, marine first aid, emergency measures and workplace hazardous materials handling. In May 1998, the company installed a software-based maintenance planning tool. Accountability of management for the effective monitoring of the tackle inspection procedures has been reinforced. With regard to the need for effective coordination and harmonization between federal and provincial authorities, Transport Canada, Marine Safety officials at both national and regional levels have started a process of consultations with the appropriate departments of the provinces and territories.Safety Action Taken Following the occurrence, Nova Scotia's Department of Environment and Labour carried out an investigation into the occurrence. Under an order issued by the department, a comprehensive examination of all standing and running rigging for fishing operations including safety chains, anchor points for rigging and wire sizes of lifting purchases and rigging gear onboard was carried out for all vessels of the fleet, including the Cape Chidley. Changes, repairs and/or replacements effected to Cape Chidley included, among others, the fitting of a new header to the bulwark stay and returning the bulwark stay to its original scantlings. Following this occurrence, National Sea Products reported that the company has extensively reviewed its internal procedures with respect to the repair and maintenance of its vessels and safety training for its crews. The importance of regular safety meetings has been reinforced. Crew have continued to participate in training. In particular, the crew of the Cape Chidley have taken further training in occupational health and safety, incident investigation, marine first aid, emergency measures and workplace hazardous materials handling. In May 1998, the company installed a software-based maintenance planning tool. Accountability of management for the effective monitoring of the tackle inspection procedures has been reinforced. With regard to the need for effective coordination and harmonization between federal and provincial authorities, Transport Canada, Marine Safety officials at both national and regional levels have started a process of consultations with the appropriate departments of the provinces and territories.